SAGE: Silver Linings and Aging Experiences Among Midlife Women Living with HIV and Diabetes. - ABSTRACT Women living with HIV and women with type 2 diabetes are living longer, yet face overlapping psychosocial and structural challenges as they enter midlife and experience perimenopause and menopause. These challenges include stigma, discrimination, social isolation, and emotional distress, which are often intensified during midlife and negatively affect engagement in care and health-related behaviors. Existing research and clinical approaches largely emphasize symptom burden and risk, with limited attention to strengths-based processes that may support adaptation and sustained healthcare engagement during this life stage. This lack of attention is a critically important gap, because despite these barriers, many women describe silver linings, defined as surprising, positive shifts in meaning, connection, and perspective that arise after adversity and contribute to renewed purpose and engagement. Building on a recent principle-based concept analysis published by our team, this R21 will examine silver linings as a strengths-based pathway to reduce stigma, support engagement in care, and improve health outcomes among perimenopausal and postmenopausal women aged 45 and older living with HIV, diabetes, or both. We will recruit N = 120 women evenly distributed across three diagnosis groups (HIV only, diabetes only, and HIV plus diabetes), with approximately 60% recruited in Houston, Texas, and 40% in Buffalo, New York. Participants will complete validated surveys assessing silver linings, stigma, discrimination, menopause symptoms, trust, social support, depression, and anxiety. Clinical outcomes, including HIV viral load, hemoglobin A1c, clinical visit attendance, and adult vaccine uptake, will be extracted from the electronic health record. Following survey completion, approximately 36 women will be purposively selected for remote qualitative interviews to ensure representation across diagnosis groups and variation in silver linings profiles, including low or absent silver linings. Using a convergent mixed-methods design, quantitative and qualitative data will be analyzed in parallel and integrated to identify key psychosocial constructs and patient-centered language relevant to strengths-based engagement during menopause and aging. As an exploratory R21, this study is designed to estimate effect sizes, refine key psychosocial constructs, and identify candidate screening domains rather than to test efficacy or causal pathways. Findings will inform the early development of a brief, strengths- based clinical screening tool intended to help clinicians recognize, acknowledge, and engage women’s adaptive strengths during routine clinical encounters. By advancing strengths-based, stigma-aware, patient-centered approaches to aging, this study directly addresses NIH PAR-25-355 priorities by supporting engagement in care among women living with HIV, type 2 diabetes, or both.
